Citation NR: 9712028
Decision Date: 04/09/97 Archive Date: 04/18/97
DOCKET NO. 95-14 728 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Cleveland,
Ohio
THE ISSUE
Entitlement to service connection for a back disorder.
REPRESENTATION
Appellant represented by: The American Legion
WITNESSES AT HEARING ON APPEAL
Appellant and A. A.
ATTORNEY FOR THE BOARD
William D. Teveri, Associate Counsel
INTRODUCTION
The veteran served on active duty from March 1988 to March
1992.
This appeal arises from a November 1994 rating decision by
the Department of Veterans’ Affairs (VA) Regional Office (RO)
in Cleveland, Ohio.
The Board notes that the veteran’s claim for service
connection for uveitis and iritis, bilateral, with defective
vision, right eye, was denied by the November 1994 rating
decision on appeal. In November 1996, during the pendency of
this appeal, the RO granted the veteran’s request for service
connection for uveitis and iritis, bilateral, with defective
vision, right eye, and assigned a 10 percent rating,
effective December 27, 1993. The veteran, however, has not
filed a Notice of Disagreement or an Appeal as to that
decision. Therefore, that claim has not been procedurally
developed for appellate review, and is not before the Board
at this time.
REMAND
The veteran’s service medical records indicate that she was
seen in March, May, September, and October 1991 for
complaints of low back pain. Findings of mechanical low back
pain, sacroiliitis and ankylosing spondylitis were noted,
although a whole body bone scan in May 1991 found no evidence
of sacroiliitis. A September 1991 service medical record
notation indicates that x-rays confirmed Marie-Strumpell
disease of the spine. However, a postservice August 1994 VA
orthopedic examination found no objective abnormalities, no
limitation of range of motion, no fixed deformities, normal
neurological findings, and normal lumbar and thoracic x-rays.
Based solely on subjective pain and a history provided by the
veteran, however, the examiner diagnosed chronic lumbosacral
strain. The RO, in denying the veteran’s claim for service
connection, interpreted the examination report to indicate
that there was no current disability.
The Board notes, further that postservice VA treatment
records dated in 1994 indicate otherwise. In July 1994,
ankylosing spondylitis was reported to be stable. In
September 1994, it was reported that ankylosing spondylitis
was strongly suspected and sacroiliitis was noted to be
clinically shown. Thus, it appears that it is unclear as to
whether the veteran does in fact have a current back
disability, and if so, whether any current disability is
related to her military service.
When, during the course of review, it is determined that
further evidence or clarification of the evidence or
correction of a procedural defect is essential for a proper
appellate decision, the Board shall remand the case to the
agency of original jurisdiction, specifying the action to be
undertaken. 38 C.F.R. § 19.9. As the VA examiner has
indicated that the veteran has chronic lumbosacral strain and
some of the recent clinical treatment records indicate that
the veteran may have ankylosing spondylitis which was also
diagnosed in service, a clarifying medical opinion should be
obtained as to the relationship between the veteran’s in-
service and current low back pain. See Myers v. Brown, 5
Vet.App. 3 (1993).
Therefore, in order to give the veteran every consideration
with respect to the present appeal, it is the opinion of the
Board that further development in this case is warranted.
Accordingly, this case is REMANDED to the RO for the
following action:
1. The RO should request that the
veteran identify all sources of medical
treatment received for the claimed back
disability since 1992, and that she
furnish signed authorizations for release
to the VA of private medical records in
connection with each non-VA medical
source she identifies. Copies of the
medical records from all sources she
identifies, and not currently of record,
should then be requested and associated
with the claims folder.
2. The RO should schedule the veteran
for VA orthopedic and rheumatologic
examinations to assess the nature,
severity, and manifestations of all back
disabilities that may be present. The
scope of the examination should be broad
enough to cover all residual conditions
which are suggested by the veteran’s
complaints, symptoms or findings at the
time of the examination. All complaints
or symptoms having a medical cause should
be covered by a definite diagnosis.
Appropriate laboratory work, x-ray
studies, and consultations should be
obtained when necessary. The examiners
should identify all back disabilities
present including those of congenital or
developmental origin. The examiners
should render an opinion as to whether
the veteran has ankylosing spondylitis or
sacroiliitis, and comment on the medical
evidence of record which includes such
diagnoses. The examiners should express
an opinion as to whether it is as least
as likely as not that any of the
currently diagnosed disabilities are
related to any back disability for which
treatment was rendered to the veteran in
service. The claims folder must be made
available to the examiners prior to the
examination for review.
3. After completion of the above
development, the RO should again
adjudicate the issue of service
connection for a back disorder. If the
determination remains adverse to the
veteran, she and her representative
should be furnished a supplemental
statement of the case and be afforded an
opportunity to respond thereto.
Thereafter, the case should be returned to the Board for
further appellate consideration, if appropriate. The purpose
of this REMAND is to obtain additional information and to
develop the veteran’s claim. The Board does not intimate any
opinion, either factual or legal, as to the ultimate
disposition in this case. No action is required of the
veteran until she is notified by the RO.
S. L. KENNEDY
Member, Board of Veterans' Appeals
38 U.S.C.A. § 7102 (West Supp. 1996) permits a proceeding
instituted before the Board to be assigned to an individual
member of the Board for a determination. This proceeding has
been assigned to an individual member of the Board.
Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Veterans Appeals. This remand is in the nature of a
preliminary order and does not constitute a decision of the
Board on the merits of your appeal. 38 C.F.R. § 20.1100(b)
(1996).
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